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Microbiological profile of leucorrhoea in patients attending a tertiary care

hospital at Jalna

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DOI: 10.18231/2455-6807.2016.0011

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Original Research Article DOI: 10.18231/2455-6807.2016.0011

Microbiological profile of leucorrhoea in patients attending a tertiary care hospital

at Jalna
Sufia M. Siddiqui1, Uzma Afreen2, Kotgire Santosh A.3,*, Karan Ostwal4, A.B. Deshmukh5
1Professor, 2Tutor, 3Assosiate professor, 4Assistant Professor, 5Professor & Head, Dept. of Microbiology, Indian Institute of
Medical Sciences, Jalna, Maharashtra

*Corresponding Author:
Email: santosh_kots2001@yahoo.com

Abstract
Introduction and Objective: Leucorrhoea is an abnormal white, yellow or greenish vaginal discharge associated with irritation,
is non-hemorrhagic in nature and signifies some underlying pelvic pathology. It is common complaint of patients attending
Obstretic and Gynaecology department. There are three main causes of vaginal discharge -1.Bacterial vaginosis (BV) 2.Vulvo-
vaginal candidiasis (VVC) 3. Trichomoniasis. Symptomatic vaginal discharge needs to be evaluated to ascertain the cause so as to
institute proper treatment. So the present study was undertaken to screen abnormal vaginal discharge in women to diagnose BV,
VVC and Trichomoniasis.
Materials and Methods: We included 175 patients with main complaints of leucorrhoea .The study was carried out in the the
Department of Microbiology, Indian Institute of Medical Science and Research Jalna, for a period of 1 year. High vaginal swabs
were taken from these patients and assessed by wet mount, gram staining, Nugent’s score and culture on respective media followed
by identification of candida on Hicrome agar.
Results: Majority of patients belonged to the reproductive age group (15-45years). Out of the 175 patients, 67(38.28%) patients
showed normal flora in which no etiology could be elicited. Remaining 108(61.71%) patients had a definite etiological agent
amongst which bacterial vaginosis was diagnosed in 68 (38.85%)patients as per the Nugent’s Score.22(12%) patients revealed
candidiasis, and 18 patients (10%) showed Trichomonas vaginalis on wet mount examination. When further speciation of Candida
were done, on Candida Hicrome agar, it was found that 13 (59.1)were C.albicans,5 (22.72%)were C glabrata,3 (13.63%)were C
parapsilosis and only one strain was C krusi(4.5%)
Conclusion: Bacterial vaginosis remains the most predominant cause of leucorrhoea in sexually active women. For confirmation
of clinical diagnosis, microbiological investigations have to be performed so as to improve the treatment outcome.

Keywords: Leucorrhoea, Bacterial Vaginosis, Vulvovaginal Candidiasis, Nugent’s Score.

Introduction cotton cheese like discharge caused by candida

Leucorrhoea is excessive vaginal discharge
commonly encountered in females of reproductive age
group (15-45 years). It may be observed in physiological
conditions like pregnancy, premenstrually, or during
ovulation. Pathological vaginal discharge occurs in 1-
14% of all women in the reproductive age group and is
responsible for 5-10 million OPD visits per year
throughout the world.(1) Three main causes of
pathological leucorrhoea are bacterial vaginosis,
candidial vulvo vaginitis and trichomoniasis.(2) Bacterial
vaginosis (33-47%)(3) is the most common cause of
symptomatic vaginal discharge, followed by candidiasis
(20-40%) and trichomoniasis (8-10%).(4,5) These three
conditions account for 90% of all etiologies of abnormal
vaginal discharge. Multiple infections can also coexist.(3)
Bacterial vaginosis is termed vaginosis rather than
vaginitis because this is associated with alteration in
normal flora rather than due to any specific
inflammation. There is considerable decrease in number
of lactobacilli in the vagina and altered pH and is
characterised by increased growth of other bacteria.
Common agents of bacterial vaginosis include
Gardnerella vaginalis, moblincus, bacteroides,
saprophytes and Mycoplasma hominis, etc.(6)
Vulvovaginal candidiasis is characterized by pruritis and
species.(7)
Vaginal trichomoniasis is associated with a copious
yellow or green sometimes frothy discharge caused by
Trichomonas vaginalis.(7)
Leucorrhoea predisposes to significant morbidity in
the form of pelvic inflammatory diseases, infertility,
endometriosis, cuff cellulitis, urethral syndrome,
pregnancy loss, and preterm labour.(8) The management
of vaginal discharge is largely syndromic and empirical,
it is usually based on naked eye examination of vaginal
discharge and that is unsatisfactory because the
diagnostic accuracy is lost without microscopic
examination.(9) It not only has a financial and social
impact leading to noncompliance on the part of patients,
but also contributes to overall emergence of
resistance.(10) Considering all these issues ,the present
study was undertaken to screen all the women presenting
with leucorrhoea and determine the microbiological
profile of symptomatic vaginal discharge in them.
Materials and Methods
This is an observational kind of descriptive study,
carried out in the Department of Microbiology, Indian
Institute of Medical Science and Research Jalna, a
tertiary care hospital, for a period of 1year from 1st June

International Journal of Medical Microbiology and Tropical Diseases, October-December, 2016;2(4):171-174 171
Kotgire Santosh A. et al. Microbiological profile of leucorrhoea in patients attending a tertiary care…....

2015 to 31st May 2016. After obtaining ethical agar, Chocolate agar, Sabourauds dextrose
committee clearance, a total of 175 women having agar(SDA). Candida species were identified after
complaints of white discharge per vaginum, abdominal 48hrs of incubation, depending on colony
or back pain, pruritis and dysuria that were referred from morphology from SDA agar. Gram stain and germ
the department of Obstetric and Gynaecology were tube testing were done for confirmation of Candida
included in the study. Informed consent was taken from albicans. For species identification of candida,
them.Patients on antibiotic treatment, those who had HiCrome candida differential agar was used.
genital prolapse, who were pregnant or who had Candida albicans produced green colonies,
delivered or aborted six weeks prior were excluded from Candida tropicalis produced blue coloured
the study. colonies, Candida parapsilosis cream coloured
colonies and Candida krusi purple coloured
Collection of sample colonies on Candida hicrome agar.
A sterilized Cusco’s speculum was inserted into the
vagina to visualize the vagina and cervix. The amount, Results
colour, character and smell of the vaginal discharge in A total of 175 patients were evaluated during a
the vagina were noted. Vaginal pH was recorded by period of one year. Majority of the patients were in the
using pH strips with in a range of pH 2.0 - 10.5 from the reproductive age group, and were married.36.57% of
mid-lateral vaginal wall. Three vaginal swabs were patients were in the age group of 26-35 years followed
collected with sterile cotton swabs from the posterior by 34.28% patients in age group of 15-25 years.(Table2)
fornix and transported to the Microbiology laboratory for
further processing. Table 2: Distribution of cases according to their age
Age No. of patients Percentage
Microscopic Examination n=175
A. Saline Wet Mount: One swab was used 15-25 years 60 34.28
immediately to prepare a wet mount with one to 26-35 64 36.57
two drops of normal saline on a glass slide and was 36-45 28 16
examined by light microscopy for the presence of Above 45 23 13.14
motile pear shaped trichomonas and pus cells. Total 175 100
B. Gram smear examination: The second swab was
taken and smears were made on a clean and grease No abnormal finding was revealed in 67 patients
free glass slide, heat fixed by just passing the glass (38.25%)(Table3). They showed normal flora i.e.
slide over the flame. Then the smear was stained epithelial cells, lactobacillus or few pus cells etc. which
by Gram’s method and observed under oil did not satisfy the Nugent’s score, so these patients were
immersion objective. The smear was evaluated for considered to be suffering from physiological
the presence of pus cells, vaginal epithelial cells, leucorrhoea. Clue cells were observed in 27.42% of
various bacterial morphotypes, clue cells & yeasts. cases on gram stain indicating bacterial vaginosis.
Large gram-positive rods were taken as Budding yeast cells were seen in 16% and Trichomonas
lactobacillus morphotypes, smaller gram-negative vaginalis in 10.28%. Trichomonas vaginalis were seen
to gram-variable rods were considered as G. as motile pear shaped protozoa on wet mount along with
vaginalis and Bacteroides spp. Nugent’s abundant polymorphoneutrophils.
score(Table 1) was applied for the diagnosis of
bacterial vaginosis.(11) The sum of the 3 scores was Table 3: Comparison of wet mount and gram
taken and a score of 7 or more was considered the staining results
“operational definition” of bacterial vaginosis. Wet mount /gram No. of Percentage
stain patients
Table 1: The Nugent scoring system for diagnosis Pus cells 20 11.42
of Bacterial vaginosis Trichomonas 18 10.28
Score Lactobacillus Gardnerella Curved
vaginalis
morphotype morphotype bacteria
per field per field (mobiluncus) Clue cells 48 27.42
per field Budding yeast cells 28 16
0 >30 0 0 Inconclusive 67 38.25
1 5-30 <1 1-5
2 1-4 1-4 >5 As per Nugent’s criteria, bacterial vaginosis was
3 <1 5-30 5-30 confirmed in 68(38.85%) patients (Table 4). 28 cases
4 0 >30 >30 revealed budding yeast cell in wet mount and gram stain,
of which 22(12%) was isolated by culture on SDA.
C. Isolation by Culture Methods: Third vaginal When further speciation of these were done, on Candida
swab was inoculated on Blood agar, Maconkeys
International Journal of Medical Microbiology and Tropical Diseases, October-December, 2016;2(4):171-174 172
Kotgire Santosh A. et al. Microbiological profile of leucorrhoea in patients attending a tertiary care…....
Hicrome agar. It was found that 13(59.1%) were
C.albicans,5(22.72%) were C glabrata,3 (13.63%)were
C parapsilosis and one strain (4.5%)was C krusi. (Table
5)
Table 4: Classification of patients as per etiological
agents
Etiological agents No. of Percentage
patients
Bacterial vaginosis 68 38.85
Candida species 22 12.57
Trichomonas 18 10.28
vaginalis
Table 5: Speciation of Candida on Hicrome agar
n=22
Species of candia No. of isolates Percentage
Candida albicans 13 59.1
Candida glabrata 5 22.72
Candida 3 13.63
parapsilosis
Candida krusei 1 4.5
Discussion
Leucorrhoea is a very distressing problem in women
of childbearing age group. In the present study, 175
women from the Obstetric and Gynaecology department
were followed for assessment of leucorrhoea. Majority
of cases were found to be in the age group of 25-35years
(36.57%) followed by 15-25 years (34.28%) This
represented the reproductive age group in our rural
population with clustering of cases around 20-25 years.
Similar peak age incidence have been reported by Rekha
et al, Lavanya et al and Masand et al.(8,2,12) This could be
because of increased sexual activity, childbirths and the
use of contraceptive devices at this age.
Bacterial vaginosis was found to be the most
common cause of leucorrhoea(38.85%) as calculated by
the Nugent’s score. Various studies have revealed
bacterial vaginosis as 32.3%(13) 26%(14) 28%.(7)
Chaudhari et al have reported incidence of bacterial
vaginosis as (36.68%).(15) Our study corresponded with
these findings.
Candidiasis was observed in 22(12%) patients,
though on direct smear, a few more cases were detected.
We considered culture as more definitive than direct
smear, hence only culture positive cases were included
in this study. Sevitha et al have reported Candidiasis in
15% of patients with leucorrhoea,(16) Masand et al have
reported Candidiasis in 14% of patients(12) while
Lavanya et al(2) have reported Candidiasis in 22.4% of
patients. The main symptom in these patients was itching
but the character of discharge could not be elucidated
properly in these patients. On speciation on candida
Hicromeagar, Candida albicans was the most common
isolate followed by Candida glabrata, Candida
International Journal of Medical Microbiology and Tropical Diseases, October-December, 2016;2(4):171-174
parapsilosis and Candida krusi. Similar findings have
been elucidated by Aring et al.(17)
Finally Trichomonas vaginalis as a causative agent
was found in 18(10%) of patients which corresponded to
the studies done by Nishat et al.(18) Overall prevalence of
trichomonal vaginosis varies from place to place and
from study to study and ranging from 6-14.9%.(2)
Another consistent finding, we observed was increase in
polymormhoneutrophils in patients suffering from
trichomoniasis.
Conclusions
Bacterial vaginosis remains the most predominant
cause of leucorrhoea in sexually active women.
Microscopic wet mount and Gram staining can be used
as reliable test for determining abnormal vaginal
discharge. Amsel’s criteria(19) of characteristic thin
homogenous consistency, pH determination, Whiff test
and clue cells to diagnose abnormal discharge correlated
with most of our cases, but the definitive diagnosis could
only be established by microbiological evidence. Hence,
physical diagnosis by Amsel’s criteria can still be
followed in resource poor setting but if facilities are
available, clinicians must bank on microbiological
evidence for proper treatment.
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